Category: Information Technology

Patient Accountability ESSENTIAL for Health Care Systems

Canadians want a high functioning health care system. This requires (but is not limited to):

  • appropriate funding
  • a seamless electronic medical record
  • strong support for Family Doctors (the back bone of a high functioning health care system)
  • a “Goldilocks” level of oversight to ensure the needs of Canada’s diverse areas are met
  • and much more

But one essential feature that is not talked about nearly enough is patient accountability.

Doctors diagnose and treat patients. More of us (thankfully) are also discussing proactive measures to prevent people from getting sick (appropriate screening, lifestyle tips, advice on menopause/andropause etc).

BUT patients also bear a vital responsibility in their own health outcomes. When patients are accountable—meaning they are informed, engaged, proactive AND use the health system appropriately—health systems perform better. In contrast, passive, non-adherent patients who misuse health care will strain health systems.

What exactly is patient accountability? Partly it’s the degree to which individuals take responsibility for managing their health. This encompasses adherence to prescribed treatments, lifestyle choices, attending medical appointments, following preventive care recommendations and so on.  Certainly patients who adhere to current guidelines for, say, diabetic care, will have fewer complications and wind up in hospital less and use health care resources less overall. This is why investing in proactive teaching for diabetics has been shown to not just improve health care outcomes, but also the cost to the health care system.

Patient accountability cannot exist without adequate health literacy. Patients must understand medical terminology, navigate health systems, and assess risks to make informed decisions. Without health literacy, patients cannot be expected to manage their care effectively. A diabetic patient who learns to read food labels, monitor blood sugar, and adjust insulin levels exemplifies accountability in practice. When one looks at just how disjointed our current health care system is, it is clear we have much work to do to improve health literacy amongst our patients – and that dollars spent to promote this, will be money well spent.

But patient accountability also refers to how patients use the health care system. Our health system is under pressure from growing demand, finite resources, and rising costs. Patient accountability plays a pivotal role in mitigating these challenges.

Non-adherence to treatment alone is estimated to cost billions annually in avoidable hospitalizations, emergency room visits, and disease complications. For example, failure to take antibiotics properly can lead to resistant infections requiring more intensive care. Likewise, patients who frequently miss appointments or use emergency departments for non-urgent needs place undue strain on systems designed for more acute care.

By contrast, when patients manage minor issues at home, access preventive care on schedule, and comply with physician recommendations, they reduce unnecessary utilization of high-cost services. This not only frees up resources for patients with more serious needs but also ensures that funding is directed toward value-based care rather than avoidable interventions.

During my time in practice, I have only seen one government paper that talked about patient accountability – the (in)famous Price-Baker report of 2015. Written by lead authours Dr David Price and Elizabeth Baker, and including luminaries like Dr. Danielle Martin on their expert committee, one of it’s ten principles stated:

“The system is built on joint accountability: Each primary care provider group is responsible for a given population and their primary health care needs. Both provider groups and citizens are expected to use the system responsibly.”

Since then of course I have yet to hear Drs. Price/Martin or any of the other authours talk publicly about patient accountability.

Dr. David Price
Dr. Danielle Martin

How does this work in other countries?

In Finland, patients are told they have the right to good care that respects their opinions and ensures that there is informed consent with treatment. This onus is on the doctors. BUT, Finland also puts accountability measures on the patients in the form of user fees. They are generally nominal, but they are there, and I would suggest, serve to make patients think about whether they are using the health system wisely.

In Norway a similar concept applies. Health care is heavily subsidized by public health insurance. However there are user fees up to a prescribed annual maximum (currently around $250 if I’ve done the currency conversion correctly). After that, all your health care needs are covered (nobody goes bankrupt if they get cancer).

Then we have the Netherlands. There you are required by law to purchase health insurance (there are many providers apparently). There are various packages from basic to more comprehensive and the costs vary. There is also, unsurprisingly, a deductible, known as Eigen Risico, which you have to pay, before your insurance kicks in. It’s mandatory.

I picked these three countries as examples because not only do have a reputation for providing excellent health care, but because they are often talked about in glowing terms by the two physicians who seem to be driving the change in Primary Care in Ontario, Dr. Jane Philpott (Chair of Ontario’s Primary Care Action Team) and Dr. Tara Kiran (principal investigator for the ourcare.ca project)

Dr. Jane Philpott
Dr. Tara Kiran

Dr. Philpott frequently mentions countries like Finland/Norway, not just in her book (Health for All) but in various interviews. Dr. Kiran has frequently mentioned the Netherlands. They have generally spoken in glowing terms about how well the health system works in those countries and how almost everyone has a family doctor there.

I’ve also never heard them talk about how those countries require patients to be accountable for how they use the health care system.

Currently, our health care system is poorly rated compared to its peers. Canadians want, and deserve a better system. But in order to get that, we need to recognize that preserving our health care system is a shared responsibility. Despite what the politicians say, you should NOT be able just to walk into a health care facility and automatically expect it to be perfect. Rather, we should all recognize that we taxpayers own the system. As owners, we have a responsibility to use it fairly, wisely and appropriately. And yes, that means putting in mechanisms like deductibles to ensure people think about how they use health care.

Or we can carry on with a health system in a perpetual state of crisis. The choice really is up to us.

Sunday Snippets: Dec 1, 2024 (ft. Bonnie Crombie, Vaccines, Microplastics and more)

Item: More and more family doctors are turning to AI scribes to reduce their workload. Many physicians in the article state time saving is the main driver for adopting these scribes.

My thoughts: I’m piloting an AI scribe right now with my Health Team. It can reduce the number of hours spent on paperwork. However, one does need to review the note dictated to ensure it’s accurate (a few examples of mistakes so far). The notes also tend to be wordier than my own notes. Finally, it’s really important to review the examination section of the notes – as the scribe has no way of knowing what a patient “looks like” and it’s up to you to ensure accuracy.

There are of course some privacy concerns. That’s why I like the fact that the scribe I’m using is not integrated into my Electronic record. That way the patients name/date of birth/health card/other identifying information does not get sent into the ether when the scribe generates a note.

My hope is the government settles on one scribe (after appropriate vetting) and pays for all physicians to use it. This will have significant positive benefits for health care.

Item: Ontario Liberal Party Leader Bonnie Crombie has launched her first campaign ad. She blames current Conservative Premier Doug Ford for the shortage of Family Physicians.

My thoughts: It’s a bit rich for the Liberals to blame the current government for the doctor shortage when most of the problems with family medicine began during their tenure. But, just as federal/national elections are won based on the cost of living/inflation (the big reason why Trump won), provincial elections in Canada are often lost based on how the current government is managing health care. And this truly is Doug Ford’s Achilles heel.

I know it seems like Ford’s handlers have him convinced that he can win a third term if only he calls an early election. But the blunt reality is that an early election call will be viewed as cynical even by people who will vote for him. Similarly the $200 Ontario “rebate” cheques are going to be viewed as a bribe.

Will Ford win a third term? I don’t know. But I doubt it will be as easy as he or his handlers think. He really needs to take some significant steps between now and the spring on health care. If only some would give him advice, and on more than one occasion.

Item: We’ve all heard about the rise in measles cases across the country and in the U.S. It seems that now Whooping Cough is also on the rise.

My thoughts: Jeez. Get vaccinated and get your kids vaccinated already people.

Item: On that note, it seems very few adults in the United States are getting updated Covid/Flu and RSV vaccines, even in high risk populations like nursing homes.

My thoughts: Life expectancy in the United States continues to fall. These two articles are not unrelated.

Item: Microplastics have now been found in the human brain.

My thoughts: Not nearly enough attention is being paid to this story. There are significant red flags for the harm that microplastics can do to human health including increasing the risk of dementia/heart disease/stroke and reducing fertility and sexual function. While it’s true that most of the studies raising alarm have been in labs or in animal models that don’t give a complete picture of the effect on humans, there are just too many concerns to ignore. We need an urgent review of microplastics (along with a review of all the processed garbage in the North American diet).

Item: A great article in the Annals of Family Medicine shows that when your doctor is away, there is LESS downstream use of ER and associated health care costs if you see a doctor in the same group practice than in a walk in clinic.

My thoughts: This is yet another reason why expansion of scope of allied health professionals is a bad idea. Rather than getting your care fragmented between health care workers who don’t have your full health history – the ideal is to support your family doctor to make sure whoever is covering can see that information, to give you better care. And on that note….

Item: Ontario is going to allow the further expansion of scope of nurse practitioners. PEI is going to allow physiotherapists to order X-rays.

My thoughts: Go read the article from Annals of Family Medicine above. This move (to expand scope) will eventually be shown to have been a big mistake.

Item: Excellent (and unusual for the Trillium – ungated) article on the aging population of family physicians in Ontario and what it could mean for the future.

My thoughts: None of this is surprising. Four of the five doctors in my clinic are late 50s or older. We are heading for a real problem if we don’t immediately support family medicine now.

Item: I somehow missed this but it seems that Australia just had its worst flu season on record.

My thoughts: I wrote this in 2017 warning that our health care system couldn’t handle a bad flu season. The situation is worse now. I don’t know what the flu season will be like, but if it’s a bad one we will see a proliferation of horror stories about health care. At the risk of sounding like a broken record – get your flu shot people. Keep yourself safe.

Yours truly getting his flu shot this year.

That’s it for this week. I’m away next week. Might have a blog later on a specific issue that is making Ontario an undesirable location to practice medicine. Back in two weeks with more snippets.

Actually, Ontario Does NOT Have a Shortage of Family Physicians….

You’re probably wondering if I’ve lost my mind. The media is currently littered with stories about how 2.3 million people in Ontario don’t have a family doctor and how that number is expected to double in two years. Family practices are closing down. In Sault Ste Marie – over 10,000 people are about to be orphaned (left without a family doctor). The Ontario Union of Family Physicians just held an event geared towards helping family doctors leave the profession.

How out of touch must I be to make the assertion, as I did on CTV news recently, that we don’t have a shortage of family doctors?

Yours truly on CTV News

Truth be told, there is an important distinction that has to made, which is key to solving the orphaned patient crisis. There are family doctors, and there are family doctors who are willing to work in a comprehensive care family practice like I do. 

According to the Ontario Medical Association (OMA) website, there are over 15,000 members of the Section of General and Family Practice. These doctors have got their medical licence, are qualified to practice in Ontario, and are able to practice family medicine without any further regulatory hurdles (like getting foreign doctors licensed would entail). There are likely many more as some doctors with a family practice billing licence don’t choose a section – but let’s go with 15,000.

What’s really telling is that only about 9,300 are in what’s called a PEM (Practice Enrolment Model – where a formal agreement exists to run a family practice). The number that are in Fee For Service alone (without an agreement) but still run a practice, is likely only a couple of hundred. So at most we have 9,500 comprehensive care family doctors. The other 5,500+ do something else (hospital only work, clinical associate work, walk in, etc).

From the OMA website. PEM + APP is about 9,300. This would be the number of docs with a formal agreement to run a family practice. 

There’s a myriad of reasons why comprehensive family practice is so unappealing, but let’s look at the two main ones.

1)Decreasing net incomes over the years. It is of course, unpopular to talk about the money doctors make. The OMA has historically felt that the general public views doctors as “fat cats” and “part of the rich elite.” So they’ve shied away from talking about physicians incomes or trying to positively frame that discussion – with predictable results.

As Boris Kralj (PhD in Economics, Adjunct Asst. Prof at McMaster and former Staff at the OMA) points out, net income for family physicians has fallen drastically over the past 20 years.

My thanks to Dr. Kralj for allowing me to share his graph.

2) Increasing Admin Burden. I think everybody has heard how family doctors now spend up to 19 hours a week doing administrative work, ON TOP of the time they spend seeing patients. This work is unpaid of course (there is no fee code for admin work). On a personal note, in about 2004, my office, which was already electronic, got a vpn (virtual private network). This allowed me to connect to he office from anywhere in the world. Initially, I thought it was great. I would go on vacation, spend 20 minutes a day taking care of messages and when I got back from vacation – I would not have the backlog of messages to deal with. 

This past summer, I went on a hiking trip with one of my sons. He pointed out that I was now spending over two hours a day going through labs and messages. Essentially, family doctors don’t have any vacation now. I don’t care what your job is or who you are, a life without any breaks is unsustainable.

Me last summer, by a lake, on vacation, checking my office messages and lab work (dummy chart)

What can be done about this? How does one make family medicine more appealing? This may rub some people the wrong way but the first step is simple. Pay family physicians more. In Ontario, the most common fee billed by a family physician is about $37. (The last time I got a haircut, I paid $40). Out of that $37 the family doctor has to pay their nurse, receptionist, rent, cleaning, supplies and so on. Gets used up pretty quickly. 

Additionally, you need to pay physicians for admin work. If there is 19 hours of admin work that needs to be done – it’s only fair that work is paid for. There are people who are skeptical this will work. To them I would point out that British Columbia has gotten 700 more family doctors since increasing the pay to family physicians. 

You mean if you increase the income for a job, more people will apply for it? Who knew?

B.C. isn’t even the province that pays physicians the most. That’s arguably, as I have written before, Manitoba. Saskatchewans new deal is also much better than what Ontario offers.

The second aspect is to reduce the admin burden for all physicians. Many experts suggest this is a process that will take time. They are the same experts that oversaw the increase in Admin work for physicians with “oh it’s just one extra click or it’s just a simple form”. 

To reduce the Admin burden significantly, one needs to drastically revamp digital health care. Get rid of eHealth Ontario and OntarioMD, and run all decisions through the Digital Health Branch of the Ministry of Health. It’s too late to unify all of our electronic medical records, but you can approve one (and only one) patient app that will allow patients to access and transfer their records to the physician of their choice to reduce duplication and waste. That’s the kind of bold steps that we need to take, not just crowing about the fact that doctors don’t have to sign hearing aid forms any more.

Look we already have 5,500 licensed family physicians in Ontario able to open up a practice. If 40 per cent did so, it would end this crisis immediately without having to resort to years long plans of modifying licensing and training requirements for foreign graduates (who in fairness are generally very good).

Do our leaders have the boldness and vision to do the right thing?

Meditech Expanse – How Do I Hate Thee?

Authour’s Note: After another frustrating time of dealing with our hospital’s health information (?) system, Meditech, I felt compelled to re-publish my altogether horrid attempt at poetry.

Meditech Expanse – How Do I Hate Thee?

How do I hate thee?  Let me count the ways.
I hate thee to the depth and breadth and height
My soul does retch when my eyes see your sight
Beginning to end, Expanse does torment
I will despise thee all my living days
Most un-needed code, for us a true blight
I hate thee truly, you dim all good light
Hate thy order entry, makes my mind craze
I hate thee with passion I will not excuse
In my Nuance, errors show up like wraiths
I hate thy med rec so I turn to booze
With my lost joy, I hate thee with the death
and anguish of soul, wrought by those who choose
This Expanse that shall surely take my last breath

– with profuse apologies to Elizabeth Barrett Browning, authour of the original “How Do I Love Thee?”

Screenshot of the highly cluttered and remarkably UN-intuitive Meditech Expanse Home Screen found on the web, presumably from one of their training modules. Patients listed are fake.

#Docxit on the Rise, Means More Trouble for Our Health System

Acknowledgement: I want to thank my friend Dr. Graham Slaughter for coming up with the term “Docxit”. Graham is not only a brilliant internist, but is incredibly talented at wordplay and music. Plus, he has really thick, lustrous wavy hair!

A bunch of stuff has come to my attention recently in my social life and on my social media feeds. I’m saddened by all of these and even more saddened by what this means for the residents of Canada.

Item 1: a friend of mine in her early 40s confided she is going to give up her family practice. She loves her patients, but the admin burden and the poor remuneration make it no longer feasible to do this work.

Item 2: two more friends of mine, also in their 40s, are actively making plans to leave medicine altogether. One of them told me she knew four family physicians (all in their 40s) who left this year alone, and two others in their 30s who have moved out of country.

Item 3: I came across a social media post from a friend of mine from my days in OMA leadership announcing he was now a real estate agent. Amongst the people congratulating him on passing his real estate exams were other physicians also saying they were look at ways of getting out of medicine.

Item 4: The family health organization I’m part of in the Collingwood area has gone from 52 family physicians to 47 as some have retired without finding a replacement, despite trying.

Provincially of course, there are many more such stories. Three family doctors in the Ottawa area left their practices earlier this year. Twenty per cent of family doctors in Toronto are planning on closing their practices in the next five years. The list goes on.

It’s not just Ontario. British Columbia is facing a “dire picture” when it comes to family physicians. Doctors Manitoba, through their excellent (now past) president Dr. Candace Bradshaw, pointed out the need for more doctors on more than one occasion. I could probably find articles from every province highlighting issues with recruiting and retaining physicians, but you get the point.

Doctors, it seems, are looking at leaving the profession (for either retirement or other jobs) in alarmingly high numbers. This phenomenon, dubbed Docxit by Dr. Slaughter, is happening at a time when our health system can arguably least afford it (if it ever really could).

This is particularly a concern as our younger physicians seem to be more likely to quit. A report by Statistics Canada suggested that up to 47% of physicians with less that 5 years experience are intending to leave or change jobs in the next three years. To be clear, they are not intending to retire, just do something other than what they’ve trained for.

From Statistics Canada

This phenomenon is not just present in Canada. The American Medical Association is concerned about “Medicine’s great resignation” as 1 in 5 physicians in the U.S. are also planning an exit in the next two years.

The situation in Europe would appear to be even more dire. The Politico article I linked to states that seven million people in France do not have a family doctor, with more family doctors retiring than setting up a practice. There is a shortage of two million health care workers in Europe. Brexit has badly worsened the shortage of doctors in the United Kingdom. Spain is running out of doctors. And so on.

Once again, those leaving appear to be over represented by younger physicians. It’s so bad that European Junior Doctors (an association of younger doctors in continental Europe) issued a press release warning the health care system there was going to collapse.

What’s going on then? Why are so many doctors leaving? I mean, despite the few (but loud) vociferous miscreants on social media, being a physician is still the most respected profession in the world (at 83% we’re tied with farmers and scientists). Studies show that Canadians trust their doctors to make the right choice for them and are afforded a measure of leeway that politicians and bureaucrats must surely be envious of. And you know that stereotype about first generation South Asian immigrants always wanting their kids to grow up to be doctors because of their status in society – it’s true (trust me, I and many of my friends lived it).

But the reality is that over the past ten years, practicing medicine has devolved to where it is no longer about caring for patients (which is what all good doctors want to do). In Canada, it’s been about fighting bureaucracy. With doctors now spending up to 19 hours a week doing paperwork (that’s a half a work week for most people) or fighting nameless, pointy headed, basement cellar cubicle dwelling bureaucrats to get them to actually pay for surgery that a patient needs, medicine is now more about who can do paperwork better than who can promote health care better.

In the United States, the rise of corporate entities eating up private medical practices has fuelled an explosion of a different kind of paper work, all with its own stresses. One study suggested that each physician spends almost $83,000 U.S. a year interacting with insurance companies.

Add to that the ludicrous number of options and waivers and liabilities and I sometimes think it’s easier to understand Einstein’s Theory of Relativity than it would be to understand U. S. Health Care. Dr. Glaucomflecken does an excellent job of explaining the frustration here:

I don’t know what the reasons for #Docxit are in Europe, but I imagine they are similar. The over bureaucratization of medicine is taking its toll everywhere. As was stated in the Politico article:

“At its core, it’s really that there is the perception that potentially medicine is no longer an attractive career choice, a choice for people to stay in for a whole career. And this will really endanger the sustainability of health care systems in future,” – Sarada Das, secretary-general for the Standing Committee of European Doctors (CPME)

There are so many crises in our health care system right now, it’s honestly hard to keep track. But two things are for certain. First, we won’t be able to fix health care without retaining doctors. Second, as more doctors opt for Docxit, we would appear to be doing a lousy job at retention.

Never Been a Better Time to Slash Bureaucracy, Inefficiency in Health Care

Recently, I was honoured to have been invited to participate in a debate hosted by the London and Area Muslim Healthcare Professionals group. The topic was a current hot button issue in health care:

“ Integrating private funding into Canada’s publicly funded health care system will help improve access, quality and equity“

I wound up having to speak against the motion, even though I actually do support the concept of increasing private sector involvement in health care with strong oversight. (I can already hear the usual suspects alleging I believe in “Two Tier American Style Health Care!”)

It’s a challenge to come up with ways to advocate for a position you don’t truly believe in, particularly when your opponent is the incomparable Dr. Saadia Hameed Jan. This woman is brilliant. Became a physician in an extremely patriarchal country (Pakistan), was an anchor on their national television service, then wound up doing more training in Canada and rose to the ranks of associate Professor at Western all the while maintaining a family practice. I had to be on my toes for this one.

Yours truly, and the amazing Dr. Saadia Hameed Jan

In the process of trying to figure out what to say, one fact continued to stand out in my mind. While one can argue about the merits of private funding, no reasonable person with any familiarity with our health care system could argue that it’s efficient.

During the debate I brought up the story of a patient of mine with cancer. She needed to see a surgeon, a medical oncologist and a radiation oncologist. When she got to the surgeon, the surgeon couldn’t access the actual imaging I had done (did have the written report, but any surgeon will tell you they want to see the pictures). The medical oncologist didn’t get the pathology report (fax machine blurred) and radiation oncology didn’t get a couple of things either.

All of which meant my patient had completely unnecessary delays in treatment. We all know that delays in treatment lead to worsened health care outcomes.

Yours truly desperately trying to hold his own at the debate.

Did the situation eventually resolve and my patient start treatment? Yes of course, after some running around and re-faxing of information and so on, but the point is that there was rather a lot of wasted time.

And that really was the genesis of my position in the debate. We have so many inefficiencies in our health care system right compared to other countries and all of that leads to waste.

Let’s look at a comparable patient in Turkiye. (Full disclosure – I do consulting work for Medicte, a medical tourism firm that provides cost effective health care services for Canadians in Turkiye). In Turkiye, my patient would have her entire health history accessible to her via eNabiz, an app on her phone that’s free to all citizens of Turkiye and allows them access to their health records. On going to see the surgeon, she would have been asked to consent to the surgeon looking at her health files, which would have allowed him, through his own software, to look at the images directly. The two oncologists could have gotten everything they needed right away as well.

Now take this patient, and multiple by 40 million Canadians, and just think of how much better everything in health care would work if we had such a system. No more specialists not getting full information. No more pharmacies losing prescriptions. No more need to repeat tests because you can’t access the tests that were done a short time ago.

Dr. Jan eloquently defending her position at our debate. (I cropped out the image of me sweating buckets!)

The really frustrating thing is that our politicians have known all along just how inefficient our health system is. Heck, Matthew Lister, a top health systems executive and now consultant wrote back in 2011 (!) that our health system had far too many bureaucrats. Back then we had 10 times as many health care bureaucrats per capita as Germany (!). Having watched health care devolve over the past decade, I dare say that ratio is worse now.

Just one example (albeit an important one) is the mess that is the digital health system in Ontario. The Ministry of Health has a digital health branch. Then you have a separate government funded arms length agency eHealth. But wait, there’s yet ANOTHER government funded agency, OntarioMD. This is complete nonsense. You don’t need three agencies to run digital health. Get rid of two of them already and have one unified vision for digital health.

I met with all three agencies during my term on the Ontario Medical Association Board and while it’s true that they are all staffed by nice people (except for one bureaucrat who’s a grade A prick), the reality is they often had competing visions for health IT and frankly, weren’t able to articulate a clear reason for their existence, or a vision for the province.

Now multiply this by all the other areas in health care and you get my drift. As Lister wrote:

“Our current health-care processes are lethargic, inefficient and unproductive. Excessive approvals (“courage in numbers,” in the words of one health-care administrator) hinder decision-making. Overproduction of documentation was cited as a necessary waste to accommodate the whims of bureaucrats.“

Health Systems and High Performance Operations Executive, Matthew Lister

This is why we have ridiculous situations in Canada like that of Christine Kaschuba, who’s had to wait years for badly needed scoliosis surgery, and now finds that she may not get it at all because the bureaucrats can’t decide whether or not to pay for the procedure.

Look, I realize that Canadians value our health care system and as such are always going to have strong opinions about the role of private companies in health care. But if we value health care so much, we should also hold our politicians to account, and ask them why we waste so much money on needless bureaucrats in the first place. Who would object to a more efficient health care system, where money is spent on doctors and nurses, as opposed to the loathsome bureaucrats who contribute to Ms. Kaschuba’s suffering.

Dr. Katherine Smart, past president of the Canadian Medical Association, said last year that the health care system is “collapsing all around us“. Surely if that’s the case, there has never been a better time for our politicians to show the courage, leadership and chutzpah needed to re-organize and reduce the health care bureaucracy and transform our health care system. Is that really too much to ask?

The Admin Burden That’s Really Killing Family Practice

Recently, there’s been a lot of talk about the “administration burden” faced by family physicians. The Ontario College of Family Physicians estimates family doctors spend up to 19 hours a week on “paper work”. Given there are only so many hours in a week, the more hours spent doing paperwork, the less hours seeing patients.

It also contributes to situations where people just get too frustrated with family medicine, and quit. Twenty percent of Toronto family doctors are planning on leaving within five years. This bad karma is not lost on medical students, who, as I mentioned in a previous blog – are avoiding family practice like the plague, worsening a crisis that has been years in the making.

But what exactly is this “administration burden”? What’s the “paper work” that is driving us all to frustration? I would argue it’s not paper per se, it’s digital.

That’s not to say there isn’t paper. I frequently get asked for completely pointless sick notes from employers, impractical forms to return to work and seemingly useless – “we agreed your patient was permanently disabled, but we want a one year update to make sure your patient is still permanently disabled” forms from the pointy headed bureaucrats at insurance companies. But I’ve taken a somewhat mercenary approach to those forms in order to keep myself sane.

A sick note costs $20 and takes about a minute to write. A form the insurance company asks for usually takes a few minutes to fill out and I charge $40-$175 depending on the form. I reconcile the fact that these forms are a burden, with the fact that at least I make money out of them. While somewhat unscrupulous on my part, it keeps me from totally blowing my lid whenever I see one of these.

No the real admin burden comes from the completely absurd and unrelenting avalanche of reports/lab work/follow up notes – all of which present to me in a haphazard way, seemingly designed to drive me to psychiatric medications.

I took the Friday of Eid ul Fitr off to celebrate with my family. On Saturday, I logged into my Electronic Medical Record (EMR), correctly realizing that if I waited until Monday, the EMR inbox would crush my sorry soul.

Unsurprisingly, I had a total of 75 labs/reports/messages about patients to review. It wasn’t so much the number of items to take care of, (truly if they were straight forward it wouldn’t have been too bad). It was rather how badly and inefficiently the information came to me that sucked all of the happiness I had enjoyed on Eid from my spirit.

One method of getting information to me is via a system called Hospital Report Manager (HRM). I look at HRM in my EMR and see a report on a renal transplant patient from Sick Kids. But the note was “uncategorized” which meant that I had to go into the HRM software and enter the category “nephrologist” in the report. The VERY NEXT report in my HRM in box was……the exact same report on the exact same patient, but this time HRM had categorized the report as being from a cardiologist – so I had to go in, change the report once again to “nephrologist” and I now have two copies of the same report.

By the way – Sick Kid’s hospital provides exceptional medical and nursing care to my patients, but ever since they switched their hospital IT systems to a company called EPIC there has been no end of issues like this. The only thing that software is epic at is causing physician distress.

That’s not all. HRM has more goodies awaiting for me. There’s a report from my colleague Dr. Collings on his expert management of a wrist fracture on one of my patients. Thorough, comprehensive, and well done. Except HRM has auto-categorized him to be a gynaecologist So yes, I either have inaccurate information in my patients chart, or I go back and re-categorize the report to reflect that Dr. Collings is an orthopaedic surgeon.

Next up, HRM has a report from an Emergency Room physician about a patient who was seen and apparently had some abnormal bloodwork. Not life threatening, so asked to follow up with me. Only problem is the blood work from the hospital doesn’t come to me via HRM. Now I have to go to that patients chart, and access yet another system called OLIS, log into that and download the lab work from the hospital. But wait the note from the ER was unfortunately late getting to me (about 10 days out). OLIS is set up to auto download for the past seven days, unless I click more buttons, and back date – which I have to do.

Next up, a report from HRM that a patient of mine had a Covid swab done. But HRM won’t tell me if the swab was positive or negative. Just that it was done. Now I go back to that patient chart and access OLIS where the result is, adding yet more steps to my day.

Next come messages (yes, that’s on top of HRM and OLIS). I note a message from the local Shoppers Drug Mart asking for a renewal of blood pressure medications for a patient of mine. Only problem is that a brief look at the chart shows I sent a one year supply of that same medicine to the Shoppers three months ago, and they accepted this and downloaded it. I tell the pharmacy staff who tell me they “can’t find it” which leads to……well, let’s just say a deterioration in the conversation.

As an aside, while I’m not allowed to endorse any specific pharmacy, I will say I’ve generally found care to be much better when provided by smaller, independent pharmacists who build relationships with their patients, rather than big chains that just seem to fly in itinerant staff.

Anyway, you get the point. In total it took about 3 hours on Saturday to sort through this mess and it just doesn’t have to be this way. The reason I wrote a blog about Health IT in Turkiye was to show that other countries do a much better job of managing this burden. I’m sure there are other examples and we need to learn from them.

The vast majority of my family practice colleagues practice family medicine because they genuinely like their patients, like providing comprehensive care, value the relationships built over time and feel like they make a difference in peoples lives. But unless we do something about this administration burden, I fear more and more will leave the profession, because at some point, being human, they just won’t be able to take it any more.

Canada’s Health Care Landscape has Changed Since the Canada Health Act

I’m honoured to have Dr. Silvy Mathew guest blog for me today. She’s a former member of the OMA Board, former member of the Physicians Services Committee, has a Master’s in Health Policy and Economics, a Certificate in Global Health and is hands down one of the smartest people I know.

Health care in Canada is governed by the Canada Health Act, a federal act that essentially states that medically necessary care provided by physicians and hospitals, will be covered by public insurance and administered by each province. 

The Act was passed in 1984, and is reflective of the type of acute medical care practiced at the time. However, in 2023 (and for at least a decade prior), medical care, through technology, medical advancements and aging, has changed drastically. Publicly covered care now, however well intentioned, is sorely lacking. Ironically, because of that, it is also very expensive.

For exampe, we lack public pharmacare  for adults despite being promised this by 2006 by then Prime Minister Paul Martin. (There is some pharmacare for seniors and children).

We lack dental care. We lack appropriate home care in an aging population that is getting weaker and frailer. We lack coverage on physiotherapy. In an era of increasing mental health burdens we lack psychotherapy.

The list goes on and on, notwithstanding the severe social issues that contribute to many of these issues (healthy food, exercise, housing and all the other social determinants of health).

Because we have not invested upfront, we pay significant costs in expensive procedures, prolonged hospital stays, and medications much of which could be minimized or avoided.

Why does it matter?

McKinsey Global Institute published a prospective analysis of 200 countries, looking forward on the impact of 52 diseases over the next two decades to quantify the social and economic gains if health is made a priority by government and private sector.  They quantified the value of health to the economy and showed that if using the existing interventions we have today, we can reduce disease burden by 40% in the next 20 years and extend “active middle age by 10 years”. This translates to an economic return of $2-$4 for each $1 invested. That’s remarkable. 

What’s the hold up? The lack of foresight, upfront cost and political inertia is costing us.

We have a shortage of healthcare professionals, and we use the ones we have, in extremely inefficient ways. For example, the lack of a proper digital health infrastructure in Ontario (like they have in Turkiye!) results in duplication of services, poor coordination, and inconsistent delivery of health care. Even the electronic services we DO have don’t capitalize on Artificial Intelligence (AI).

Technology advancement is a double edged sword. There are benefits to patients in terms of ongoing updated guidelines for care. But health care workers are having to do more, monitor more and change practice styles more, all leading to more individual HCW time.

Each test, often results in further testing or reassessment down the line, which compounds the problem. It’s rare that physicians just close the door on one issue a day.

Again, at the time of the Canada Health Act, we were practicing acute, limited health care. Today’s world is focused on prevention and chronic illness with monitoring. That shift has placed a huge burden on physicians time to review, inform/educate, coordinate new referrals and remind individuals to do monitoring.  Much of the time, it seems like we still don’t know how much benefit we will get from this. Hopefully the data will show we were correct to do this.

To collect and review the data though, we would need better digital systems to capture the information, which we don’t have.

Some people imply this will be managed with more “healthcare team members”. I think a huge solution for this particular issue is investing in technology and AI solutions.

Right now, we are trying and failing at holding back an avalanche.  We have technological advancements, but limited access to those. We have lack of integration of our digital infrastructure. An ageing population is leading to increased needs. But an aging health care work force is seeing retirements and illness leading to less access. New providers are available but their impact is less clear due to lesser training and duplication of services leading to increased costs. Delayed diagnoses are leading to worsened health outcomes and more expensive care. There is less preventative care due to a shortage of family physicians which leads to delayed diagnoses, worsened health outcomes and more expensive care. Lack of care giver support and home care support means that people are leaving the workforce to care for ill relatives which leads to hospital dumping. Burnout is endemic in health care, due to a feeling of disrespect and an inability to practice best patient care.

And so, physicians are in all areas of the country are giving up and closing their practices.

In the meantime, while we wait for our wishes to come true, there is opportunity to push the envelope and to drive change. People are desperate and they want options.

When access to health care is inadequate, people will choose out of jurisdiction options for delayed procedures and even screening tests. There is a moral hazard involved. People are taking risks by going elsewhere under the assumption that they will be taken care of properly.

However, with any challenges, there are opportunities. Some “non-medically necessary” medical tests (eg. screening for vitamin D) are not covered by medicare. However, it’s increasingly viewed as an early intervention. We will only see technology increase these options as better screening methods become available, and governments delay paying for them. Perhaps instead of waiting for open heart surgery or stenting, there may come a day where preventative procedures can be used to dissolve plaque in the heart arteries.

Health care faces inescapable and exponential change. However, it is unlikely, at least in the near future, that Canada (or any country’s) public health system will be able to keep up with technology and demand.

Oh for some strong, principled leadership that can see these challenges and address them head on, without resorting to political sound bites.

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Canada Should Look to Turkiye for Health Information/Data Systems

Disclosure: I have a business relationship with Medicte, a firm that provides high quality medical tourism services for Canadians. They provided me with some information for this blog. If you are on a prohibitively long waiting list for medical or surgical services, and are willing to consider travelling out of country to have treatment, contact Dr. Abdullah Erdogan at: medical.developer@mestassistance.com

I’ve written previously about Health Data Systems and what a poor job Ontario (and indeed all of Canada) does at using information technology (IT) to help with health care. Let’s look at country that does things the right way, Turkiye (formerly Turkey). I appreciate this choice may come as a surprise to many, but Turkiye has a very modern, highly efficient health care system, and had to go through their own period of transformation from a fragmented system to a more integrated one.

The long version of how Turkiye evolved their health systems can be found here. The short version is that in 2003, the Turkish government came up with the political will to introduce the Health Transformation Program. Over the next ten years this act, and unyielding political will, transformed the Turkish health care into a fully integrated system. In many ways, it’s a model for what Canada needs to do.

I had the honour of being invited to do a talk for the Canadian Turkish Business Council on the Canadian health system (along with my smarter and more esteemed colleagues Drs. Nadia Alam and Silvy Mathew). In preparation, I studied up on how Turkiye handles health data (with the help of Medicte). I cannot tell you how impressed I was with their system.

Drs. Nadia Alam, Silvy Mathew and yours truly speaking at a meeting sponsored by the Canadian Turkish Business Council

In Turkiye, the federal government has mandated that all hospitals in Turkiye use the Hospital Information Management System (HIMS). Now to be clear, different hospitals in Turkiye still use some different modules of software, but they are all compatible with HIMS. The data for all citizens of Turkiye is then backed up securely.

Then, every citizen of Turkiye is offered a patient portal called e-Nabiz.

Official logo of Turkiye’s patient portal.

What does this portal allow patients in Turkiye to do? According to Medicte:

“When people enter their E-Nabız profile, they can make appointments at all public hospitals and access the records of these appointments. They can review all of their examination, diagnosis and treatment data in the health facilities they visit and access the details of all the tests performed during this process. This includes all data related to the process, such as all laboratory tests and radiology images with their reports, prescriptions, diagnoses and drug usage details.” 

Further more, the app can be used to allow other health care providers access to patients health information (with consent). Let’s say a resident of Istanbul happens to travel to Antalya (a truly lovely tourist destination about an 8 hour drive away). If that person gets ill, they can use the E-Nabiz portal to allow doctors in Antalya to see their previous health information to help guide their care. Not only that, information about their visit in Antalya will automatically be available to their family doctor in Istanbul, including lab work, diagnosis, and prescriptions. I can’t even get health information on patients of mine that go to a walk in clinic in Barrie, and that’s only 30 minutes away from my office.

Not only does this system allow for much better communication between health care professionals of all kinds (physicians, nurses, pharmacists, home care and so on), but having knowledge of a patient’s previous health history significantly reduces duplication of tests. And leads to more optimal outcomes.

For people who are not citizens of Turkiye, but go there for medical tourism (Turkiye is one of the top medical tourist destinations in the world), their travel companies can offer them similar access to their health care records. For example, Medicte will soon offer the MestCard app via its parent company MestGroup.

Screenshots of the MestCard Apps

Essentially, a patient of mine, who choses not to wait the 13 months that they currently have to wait for a hip replacement in my area, could go to Turkiye next month, get their hip replaced AND have much better access to all their health records than a patient of mine who got that done in Canada. (And yes, all of these apps/software/portals are compliant with recent security standards).

But that’s not all, this tight integration of IT allows for other benefits. For example, Health Systems Consultant Matthew Lister, who spoke at the same event, informed how this allowed hospitals across Turkiye to manage their supply issues. If one hospital was short on something (tubing, a drug, IV fluid or so on), it can immediately check the inventory of nearby hospitals and request a transfer. No phone calls, no double checking. It’s all online, backed up, and available for hospital management to see. He also emphasized that this has been the case in Turkiye since at least 2011!

Matthew Lister speaking at the Canadian Turkish Business Council event.

In Canada, given the disastrous current state of our health care system, there have been calls for system transformation from multiple sources. Whether from what are viewed as conservative organizations like the Fraser Institute and Postmedia News, or progressive organizations like Canadian Doctors for Medicare and the Torstar Media group, everyone from all sides of the political spectrum agrees that health care is need of a fix.

Here’s thought. Rather than start from scratch, let’s look at countries like Turkiye, that have taken their own fragmented health care systems, unified them and leapfrogged Canada to develop a much more efficient health system. Then just do what they did.

The benefits to the citizens of Canada would be enormous.

Post Script: While it’s true that Turkiye has a modern, high functioning health system, even such a system can be overwhelmed by a disaster like the recent Earthquake that has claimed at least 50,000 lives. To help the victims of the earthquake in both Turkiye and Syria, I encourage you to donate to the IDRF Earthquake Relief Fund.

Federal-Provincial Health Care Deal Fails Canadians

This blog has been updated to reflect that the fact that the offer from the federal government has been accepted by the provinces.

Lots of chatter about what is an agreed upon funding formula for Health Care between the provinces and the federal government. Some astronomical dollars are being thrown around and called investments in health care. But at the end of the day, will this deal mean better health care for Canadians? The sad answer, is likely no.

One of the advantages(?) of being old is that you’ve lived through lots of things, and can see the past repeating itself. Case in point, in 2004 then Prime Minister Paul Martin introduced a health care “accord” that was designed to “fix health care for a generation“. Essentially the federal government ponied up an eye watering amount of money then, and the provinces were to implement targeted programs that would:

  • Reduce wait times
  • reform Primary Care
  • Develop a National Home Care program
  • Provide a National Prescription Drug Program (by 2006!)

Now Primary Care reform did happen in Ontario, with the development of capitation based payments to family physicians. Think of it as a salary with performance bonuses and you get the gist. There was also the implementation of some Family Health Teams. I’m unaware if any of these were implemented in other Provinces. I do note with interest that British Columbia is only now getting around to reforming primary care with their own new payment model for family physicians.

But both of these programs in Ontario were summarily slashed by then Health Minister Eric Hoskins and his servile deputy Health Minister Dr. Bob Bell in 2015. Indeed their unilateral freezing of the capitation model significantly damaged primary care in Ontario, and the effects of their folly are still being badly felt today by the 2 million residents of Ontario without a family doctor.

OMA Board Vice Chair Audrey Karlinsky put it best on Twitter.

Wait times for surgical procedures however, continued to rise, and I have no idea whatever happened to the National Home Care program.

For those of you paying close attention, the same Eric Hoskins who stopped Primary Care reform in Ontario, went on chair a federal advisory council with the goal of creating a National Prescription Drug Program……….in 2018. Which hasn’t been implemented yet. I suppose being 17 years overdue is not bad by government standards.

By the way, this whole process is basically recycling a failed politician to recycle a failed government promise. And politicians seriously wonder why average Canadians like me are so cynical??

So now, 19 years later, Canadians are being told that the provinces have accepted a federal government proposal to put an eye watering $196 billion into health care, according to Prime Minister Trudeau. But wait they were committed to $150 billion anyway so it’s really only $46 billion more, but wait, when you take out the planned budgeted increases it’s only $21 billion more. Whatever.

In return, for however much money it really is, Trudeau promises there will be “tailored bilateral agreements to address“:

  • Family Health Services
  • Health workers and the backlog of health care
  • Mental health and substance abuse
  • Modernized health care system

Our politicians need to study Albert Einstein a bit more.

Here’s the sad truth about our health care system that no politician, of any political stripe seems to be willing to admit. The system is dying and in need of radical surgery. It needs a bold, transformative vision that will completely change the way we deliver health care and will leverage technology appropriately. Anything less is simply more of the same, and will not stave off the inevitable collapse of the system.

How then do we achieve this transformation that is essential to the well being of Canadians? I will go into some further thoughts about this in future blogs, but first I would implore our political leaders to stop listening to old voices who have been advising for decades (if their advice had been good we wouldn’t be in this mess). It’s time to seek out some newer voices who have bright ideas on how to restructure health care delivery in Canada.

It’s also time to wrest control of health care data management from the current group of bureaucrats in charge of it. We can’t transform health care in Canada without a robust health care IT infrastructure and the current group simply is not getting it done.

As mentioned, I will put some more though into how, in my opinion, health care can be transformed in the future. But for now, just know that whatever the numbers or promises being tossed around, the blunt reality is that it all amounts to trying to spend you way out of trouble.

When has that ever worked out well?